In our last post, we talked about insurance claim denials, a common scenario, and things you need to know before appealing to the insurance company.

Now we will discuss here some distinguished insurance claim denial cases and how you should contest them if you face the scenario:

  • Scenario 1Your claim is denied as you didn’t file it on time

Solution – Call the billing department of your service provider to re-submit the bill with proof of filing. Even if they can’t provide the proof of filing the bill on time, you are not responsible to pay the bill. The insurance company must adjust the bill amount.

  • Scenario 2 – You have submitted the claim properly and it has been denied as “the service is not covered”

Solution – If the service isn’t listed under the policy coverage benefits, it should be on the exclusion list. If it isn’t listed anywhere, ask your insurance company to provide a proper reason for the denial.

Your claim might also get denied just because it wasn’t pre-authorized. You need to know about it. Contact the hospital and ask about the pre-authorization.

  • Scenario 3 – The insurance company asked you for more information about the claim you have requested. They won’t disburse the money until you provide the documents and the process will be on hold.

Solution – The bill shouldn’t be charged to you. It is the duty of your service provider (like hospitals) to send all the documents to your insurance company. This must happen before billing you.

  • Scenario 4 – The applied service isn’t covered under your insurance policy. These are like eye examination, medicine, glasses, and lenses.

Solution – Check your insurance plan. Most of the policies cover certain surgeries like a cataract surgery. Read your policy documents properly.

  • Scenario 5 – Your insurance plan is capped with a certain amount. You can’t get more even if you apply for it. And in this case, you have reached your limit.

Solution – Read the policy papers carefully and know your maximum benefit limit. You might have touched the line, but you may also get good discounts from the insurance company as a contracted discount.

  • Scenario 6 – Payment for a special medical treatment is included in the money allowed for a similar treatment done on the same day. No additional money will be compensated further.

Solution – The patient is not responsible for the special treatment cost. If you’re charged for the treatment, ask your insurance provider to adjust the cost.

Now let’s check out how to appeal to the most important individual insurance claim denial:

# Healthcare claim denial

Your health insurer may refuse to disburse your claim. But, you have the right to appeal against it.

Ask your insurer to reconsider the matter and demand an explanation about the denial. If you aren’t getting satisfied with the reasons, you can appeal the claim denial in 2 ways.

1) Internal appeal – Ask your insurance company to perform a full and clean review of the claim. If it’s urgent, force them to do it asap.

You must fill out all the forms given by the insurer and provide the health insurance ID with a claim number. You may also need to submit additional documents like a letter from the doctor (special case only). You can also take help from the consumer assistance program in your state. Whatever you want to do, do it within 180 days of receiving the denial letter. An internal appeal can take 30 to 60 days to complete.

Denials that need internal appeal:

  • You are not getting the benefit under your health plan as promised.
  • You have the medical issues before you opt for the health plan.
  • The requested medical treatment is addressed as “not medically required”.
  • Denial related to medical treatment which is investigational or experimental.
  • You’re no longer enrolled or eligible for the health plan.
  • False or incomplete information based on cancellation of coverage.

2) External review – You can appeal to a third party to conduct a review. The final decision will be taken by the third party, not the insurance company.

You may need to send a letter for an external review within 60 days of getting the final denial from the insurer. If the case goes into your favor, the external reviewer will give the final decision to approve the claim. Your insurer must obey the verdict by law. The review must be decided within 60 days after the request.

Denials that needs external review:

  • Medical claim denial where your insurance company have issues with the health plan
  • Denial related to medical treatment which is investigational or experimental
  • False or incomplete information based on cancellation of coverage.

The Department of Health and Human Services (HHS) can conduct an external review for your health insurance denied claim if you don’t have an external review process in your state. If your health plan is sponsored by your employer, you may not request for a state-run external review.

The final decision is served by a written notice within 48 hours after the decision is made by the reviewers.

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